ENGLISH ABSTRACT: Nursing documentation is the written evidence of nursing practice and reflects the accountability of nurses to patients. Accurate documentation is an important prerequisite for individual and safe nursing care. It is a severe threat for the individuality and safety of patient care if important aspects of nursing care remain undocumented. Nursing staff cannot rely on information that is not documented. Every patient is important and unique hence every patient’s care is individualised and different according to his/her needs. This is why important aspects of his/her care need to be documented. Ultimately, the documentation practices reflect the values of the nursing personnel (Isola, Muurinen and Voutilainen, 2004:79-80).
The goal of this study was to investigate documentation of nursing care with reference to current practices and perceptions of nurses in a teaching hospital in Saudi Arabia
Specific objectives of the study were:
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to identify whether the hospital policies are being carried out
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to identify whether the procedures regarding current documentation are being carried out and
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to explore the perceptions of the nurses regarding the current documentation practices.
Research Methodology
For the purpose of this study, a non-experimental descriptive design with a quantitative approach was used. The study was carried out at King Faisal Specialist Hospital in Jeddah in Saudi Arabia. The total population of 90 registered nurses were used in this study. Questionnaires were distributed to the participants and they were answered with no identities written on the questionnaires. After the questionnaires were completed, it was posted in a box and was collected by the researcher. The questions are straightforward, easily understood, unambiguous, non-leading, objectively set and aimed at obtaining views, experiences and perceptions of documentation of nursing care. . Involvement of participants was voluntary and non-coercive. Data analysis were carried out with the support of a statistician, expressed in tables, frequencies and statistical associations were done between various variables based on a 95% confidence interval.
The study revealed that:
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Hospital policies are being carried out N=76 (95%)
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Procedures pertaining to documentation of nursing care are being carried out N=67(83,7%).
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Nurses N=45(56,3%) indicated that paper documentation included a lot of paperwork.
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The Cerner (computer system) is regarded as the best system ever used for documentation of nursing care N=44(55%)
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The Mycare system (medication ordering system) is regarded as the most reliable, user-friendly system and nurses are happy with it N=68(85%)
Recommendations are:
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Nurses still need to be taught about the hospital policies
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Nurses should be taught the correct procedure on documenting the patient data
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Nurse clinicians and managers should check the Cerner for compliance with regard to documentation of physical assessment when conducting audits
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Use of paper for nursing documentation should be minimized by shifting some of the nursing documentation procedures from paperwork to electronic version
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Continuous updating, in-service training and monitoring to keep nurses abreast with the dynamic nature of computer usage
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Reviewing of the system, troubleshooting and suggestions from users need to be attended to on a continuous basis
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It is recommended that a backup system (generator) is in place to ensure continuity of documentation.